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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignThe <br /> APPLICATION <br /> 1 <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> 3 <br /> Applicatio hereby made to arty on business in the jurisdictional area of the oaqui�Local Health <br /> L Business N p�tlrict <br /> e (DBA) <br /> f1"C Address ta L1rai <br /> i Owner ►''1 �� jAddress 1 <br /> a <br /> Firm Partners, Addresses and Te hone Numbers t2 <br /> a Business Telephone No. 612 3- CS Emergency Telephone No. <br /> dcdc Contractor Licence No. n- <br /> 1� C• R 6 Date <br /> L Applicants Name (Print) Title �Q <br /> Please check Applicable Category (1-7)and Fill in the Required Information /„ f <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> k <br /> For July 1, June 30, 19 Disposal Sites <br /> 7 <br /> Description(Make/Yr., Color) <br /> CAL. License No. CAL. Liccse Renewal No. <br /> Serial No. � <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address j <br /> 2. ❑ PUMPER YARD i <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored �Z <br /> 3. ❑ PERCOLATION TEST Q' <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test Location <br /> 4. 0 SANITATION PER I mylf 1tcco 0-1 <br /> Job Address/Location ��� <br /> Owner L''-°V�LBL-IL N// Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ElPERMANENT 11TEMPORARY © NEW ® REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 �v /p � .J�l � <br /> Type Construction Disposal Site ' D0 <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location G <br /> Plant Capacity No, Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,"state caws, an�s and regulations a�i Joaquin Local Health District. <br /> APPLICANTS SIGNATURE X <br /> f FOA DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMBASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> s �s <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> I <br /> OTHER <br /> J� <br /> 0-7 <br /> —7Issuance Date Mailed "Delivered. <br /> Received b - Date Receipt Na. Permit No.. <br /> i APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2409" STOCKTON,CA 95201_ <br />